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  Citation statistics : Table of Contents
   2008| May-June  | Volume 74 | Issue 3  
    Online since June 25, 2008

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Stevens Johnson syndrome, toxic epidermal necrolysis and SJS-TEN overlap: A retrospective study of causative drugs and clinical outcome
Vinod K Sharma, Gomathy Sethuraman, Anil Minz
May-June 2008, 74(3):238-240
DOI:10.4103/0378-6323.41369  PMID:18583791
Background and Aims: Stevens Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) and SJS-TEN overlap are serious adverse cutaneous drug reactions. Drugs are often implicated in these reactions. Methods: A retrospective analysis of inpatients' data with these dermatological diagnoses were carried out for three years, to study the causative drugs, clinical outcome, and mortality in these conditions. Results: Thirty patients (15 TEN, nine SJS-TEN overlap, and six SJS) were admitted. In 21 cases, multiple drugs were implicated whereas single drugs were responsible in nine. Anticonvulsants (35.08%) were the most commonly implicated drugs followed by antibiotics (33.33%) and NSAIDS (24.56%). Twenty-five patients recovered whereas five died (four TEN, one SJS-TEN overlap). Conclusion: Anticonvulsants, antibiotics and NSAIDs were the most frequently implicated drugs. TEN causes higher mortality than both SJS and SJS-TEN overlap.
  24 18,484 1,351
Comparison of potassium hydroxide mount and mycological culture with histopathologic examination using periodic acid-Schiff staining of the nail clippings in the diagnosis of onychomycosis
M Manjunath Shenoy, S Teerthanath, Vimal K Karnaker, BS Girisha, MS Krishna Prasad, Jerome Pinto
May-June 2008, 74(3):226-229
DOI:10.4103/0378-6323.39584  PMID:18583788
Background: Onychomycosis is a common problem noticed in clinical practice. Currently available standard laboratory methods show inconsistent sensitivity; hence there is a need for newer methods of detection. Aims: This study involves comparison of standard laboratory tests in the diagnosis of onychomycosis, namely, potassium hydroxide mount (KOH mount) and mycological culture, with histopathologic examination using periodic acid-Schiff (PAS) staining of the nail clippings. Methods: A total of 101 patients with clinically suspected onychomycosis were selected. Nail scrapings and clippings were subjected to KOH mount for direct microscopic examination, culture using Sabouraud's dextrose agar (with and without antibiotics) and histopathologic examination with PAS staining (HP/PAS). Statistical analysis was done by McNemar's test. Results: Direct microscopy with KOH mount, mycological culture, and HP/PAS showed positive results in 54 (53%), 35 (35%), and 76 (75%) patients respectively. Laboratory evidence of fungal infection was obtained in 84 samples by at least one of these three methods. Using this as the denominator, HP/PAS had a sensitivity of 90%, which was significantly higher compared to that of KOH mount (64%) or mycological culture (42%). Conclusions: Histopathologic diagnosis with PAS staining of nail clippings was the most sensitive among the tests. It was easy to perform, rapid, and gave significantly higher rates of detection of onychomycosis compared to the standard methods, namely KOH mount and mycological culture.
  19 12,543 687
Adverse effects of antiretroviral treatment
Ajay Sharma, Roshni Vora, Megha Modi, Archana Sharma, Yogesh Marfatia
May-June 2008, 74(3):234-237
DOI:10.4103/0378-6323.41368  PMID:18583790
Background: The introduction of highly active antiretroviral therapy (HAART) has led to significant reduction in acquired immune deficiency syndrome (AIDS)-related morbidity and mortality. Adverse drug reactions (ADRs) to antiretroviral treatment (ART) are however, major obstacles in its success. Aims: We sought to study the adverse effects of ART in a resource-restricted setting in India. Methods: Hundred patients on ART were studied prospectively over a period of two years. All patients were asked to visit the clinic if they developed any symptoms or on a monthly basis. They were screened clinically and investigated suitably for any ADRs. Result: Out of the 100 patients, ten patients did not come for follow-up; only 90 cases were available for evaluation. ADRs were observed in 64 cases (71.1%) - the maximal frequency of ADRs was seen with zidovudine (AZT) (50%) followed by stavudine (d4T) (47.9%), efavirenz (EFV) (45.4%) and finally, Nevirapine (NVP) (18.4%). Most common ADRs were cutaneous (44.4%) followed by hematological (32.2%), neurological (31.1%), metabolic (22.2%) and gastrointestinal (20%). Most common cutaneous ADRs observed were nail hyperpigmentation (14.4%) and rash (13.3%). Immune reconstitution inflammatory syndrome (IRIS) was observed as a paradoxical reaction to ART in 20 (22.2%) cases. Conclusion: To optimize adherence and thus, efficacy of ART, clinicians must focus on preventing adverse effects whenever possible, and distinguish those that are self-limited from those that are potentially serious.
  18 13,777 1,077
Current regimen of pulse therapy for pemphigus: Minor modifications, improved results
JS Pasricha, Poonam
May-June 2008, 74(3):217-221
DOI:10.4103/0378-6323.41366  PMID:18583786
Background: If administered properly, dexamethasone cyclophosphamide pulse (DCP) therapy has the potential to effect lifelong recovery from pemphigus. Aims: The objective of this paper is to highlight various parameters of DCP therapy and also, to report the effects of a few modifications in the regimen. Methods: An analysis of 123 patients treated with the DCP/DP regimen over a period of five years (1998 to 2002) is presented here. Seventeen patients who did not start/continue the treatment and three patients who died during the treatment have been excluded from the analysis. Twenty patients who had not yet started families were given only dexamethasone pulses (DPs) while 103 patients received DCPs. Low dose (50 mg/day) cyclophosphamide was used as in the standard regimen. The three modifications introduced into the regimen were: (1) an additional daily dose of oral betamethasone sufficient to control the disease activity during phase I, which was progressively tapered off completely as the patient recovered, (2) use of systemic antibiotics if the patient had skin lesions, and oral anti-candida drugs if the patient had oral ulcers until complete healing, and (3) insistence on thorough cleaning of the skin and scalp with a normal soap and shampoo, and proper maintenance of oral hygiene in spite of skin/mucosal lesions. The regimen consisted of DCP/DP repeated in exactly 28-day cycles, along with 50 mg cyclophosphamide per day, insistence on completing the treatment and avoiding irregular pulses in all patients. The number of DCPs/DPs during phase I varied in different patients depending upon the dose of betamethasone used and the rate of recovery, but phase II (nine DCPs/DPs in exactly 28-day cycles along with 50 mg cyclophosphamide per day) and phase III (only 50 mg cyclophosphamide per day) was fixed at nine months each. This was followed by posttreatment follow-up (phase IV). Results: At present, all the patients are in complete remission. The confirmed period of posttreatment, disease-free follow-up period has already been more than five years in 62 patients, 3-5 years in 41 patients, 2-3 years in three patients and less than two years in six patients. Eight DCP patients and three DP patients developed a relapse (the relapse rates thus being 7.7 and 15% respectively) and received a second course of pulse therapy. They are also in remission at present. The duration of phase I was three months in 62 patients, 4-5 months in 28 patients, 6-9 months in 13, 10-12 months in nine patients and more than 12 months in 11 patients. The maximum daily dose of betamethasone used in these patients was nil in 17 patients, 1-2 mg in 85, 3-4 mg in 16, and >4 mg in five patients. Conclusions: The modifications employed in this study could ensure the cure of all pemphigus patients by using DCP therapy administered at a private clinic.
  14 15,385 1,778
Clear cell acanthoma: New observations on dermatoscopy
Figen Yazkan Akin, Ilgen Ertam, Can Ceylan, Alican Kazandi, Fezal Ozdemir
May-June 2008, 74(3):285-287
DOI:10.4103/0378-6323.41396  PMID:18583817
  12 5,831 244
Human papillomavirus and skin tags: Is there any association?
Sachin Gupta, Ritu Aggarwal, Somesh Gupta, Sunil K Arora
May-June 2008, 74(3):222-225
DOI:10.4103/0378-6323.39585  PMID:18583787
Background: Low-risk human papillomavirus (HPV) infections are related to the genesis of various benign lesions. In an isolated report available, HPVs have been implicated in the causation of skin tags too. Aims: The present study was designed to detect the existence of low-risk HPV types 6 and 11 in cutaneous soft fibromas (skin tag) in north Indians. Methods: A total of 37 cases of skin tags from various sites were analyzed. Highly sensitive and comprehensive polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) assays were done for the detection of low-risk HPV types 6 and 11. Results: The results revealed the presence of HPV DNA 6/11 in 48.6% of the skin tags examined by PCR-RFLP. Conclusion: This result corroborates the hypothesis that HPV plays a part in the etiology of benign lesions like cutaneous soft fibromas. The identification of HPV 6/11 in these lesions, which are benign proliferations of the skin, further expands the spectrum of HPV-linked lesions.
  12 40,939 356
Glomus tumor-induced longitudinal splitting of nail mimicking median canaliform dystrophy
SB Verma
May-June 2008, 74(3):257-259
DOI:10.4103/0378-6323.41375  PMID:18583797
Median canaliform deformity of the nail is an uncommon entity, where there is longitudinal splitting of the nail. Longitudinal splitting of the nail is a rare phenomenon and can also occur following number of growths arising in the nail matrix. On examination there was a longitudinal split in the nail plate, beginning in the distal nail fold and extending proximally all the way to the proximal nail fold. There was a small, almost indiscernible, swelling in that area, which was exquisitely tender. The split part of the nail showed a little discoloration. There was no discharge, bleeding, or subungual mass visible. 'Love test' was positive in this case. After nail avulsion, a small 2 mm x 4 mm nodule was exposed and excised. Histopathological examination of the tumor showed a mantle of glomus cells surrounding the blood vessels.
  9 8,633 239
Herpes simplex virus 2 infection: A risk factor for HIV infection in heterosexuals
K Anuradha, H Maan Singh, KVT Gopal, G Raghu Rama Rao, TV Ramani, Jyothi Padmaja
May-June 2008, 74(3):230-233
DOI:10.4103/0378-6323.41367  PMID:18583789
Background: Genital ulcerative disease is one of the risk factors for acquisition of HIV. As HSV-2 infection is currently the most common cause of genital ulcerative disease, it acts as a potential risk factor for HIV infection. The present study was undertaken to know the seroprevalence of antibodies to HSV-2 in HIV seropositive individuals and in the general population, and to ascertain if HSV-2 is a risk factor for developing HIV infection. Methods: The study group included one hundred new HIV seropositive persons irrespective of active genital herpes or history of genital herpes. Fifty age- and sex- matched healthy volunteers were included as controls. In all patients and controls, diagnostic serology was done for HSV-2 using HSV-2-specific glycoprotein IgG2 by indirect immunoassay using the ELISA test. Statistical value 'P' was calculated using the Chi-squared test. Results: Out of the 100 HIV seropositives, 66 were males and 34 were females with an age range of 20-54 years. In only 22 (19 males and 3 females) of these, positive history of genital herpes was obtained. In 49 out of the 100 HIV seropositives, IgG2 antibodies against HSV-2 were detected. In the control group, 11 out of 50 controls were seropositive for HSV-2 IgG2 antibody. There was a statistically significant association between HSV-2 and HIV seropositivity with 'P' value < 0.005. Conclusion: The high prevalence of HSV-2 seropositivity in the HIV-infected group (49%) as compared to normal controls (22%) was statistically significant. Prior HSV-2 infection could be an important risk factor for acquisition of HIV in our patients.
  8 6,104 354
Suspected cardiac toxicity to intravenous immunoglobulin used for treatment of scleromyxedema
MP Binitha, G Nandakumar, Daisy Thomas
May-June 2008, 74(3):248-250
DOI:10.4103/0378-6323.41372  PMID:18583794
Scleromyxedema is a rare, generalized form of lichen myxedematosus, which may be associated with systemic involvement and can be fatal. The therapeutic options available provide partial or inconsistent response and are associated with significant adverse effects. We report a case of scleromyxedema with cardiac involvement, treated with low-dose intravenous immunoglobulin, with almost complete clearing of the skin lesions. The patient died after three cycles of treatment, possibly due to myocardial infarction.
  7 4,936 248
Goldenhar syndrome with unusual features
Bijal Mehta, Chitra Nayak, Shankar Savant, Sangeeta Amladi
May-June 2008, 74(3):254-256
DOI:10.4103/0378-6323.41374  PMID:18583796
We report here the case of a 17 year-old girl with the classic signs of Goldenhar syndrome in the form of multiple accessory tragi, bilateral ocular dermoids, mandibular hypoplasia (micrognathia) and cervical lordosis. She also had a high arched palate, gingival hypertrophy and malaligned teeth, features which are as yet unreported.
  7 8,537 469
Kaposi's varicelliform eruption associated with the use of tacrolimus ointment in two neonates
Hajime Kimata
May-June 2008, 74(3):262-263
DOI:10.4103/0378-6323.41378  PMID:18583800
  7 3,705 182
Suprapharmacologic doses of intravenous dexamethasone followed by cyclosporine in the treatment of toxic epidermal necrolysis
Reena Rai, CR Srinivas
May-June 2008, 74(3):263-265
DOI:10.4103/0378-6323.41379  PMID:18583801
  7 4,505 322
Erythema multiforme following vaccination in an infant
Sarvjit Kaur, Sanjeev Handa
May-June 2008, 74(3):251-253
DOI:10.4103/0378-6323.41373  PMID:18583795
Erythema multiforme is a cutaneous reaction pattern precipitated by varied agents, notably herpes simplex and drugs. It predominantly occurs in adolescents and young adults but may be seen at other ages also. While vaccination is rarely a precipitating factor for erythema multiforme, it may occasionally be seen in infants and children. We report here a case of a two month-old infant with lesions of erythema multiforme minor appearing after two weeks following vaccination for DPT, Hepatitis B and influenza.
  6 11,154 363
Rapidly increasing incidence of Kaposi's varicelliform eruption in patients with atopic dermatitis
Hajime Kimata
May-June 2008, 74(3):260-261
DOI:10.4103/0378-6323.41376  PMID:18583798
  6 3,290 197
Clinico-mycological profile of dermatophytosis in Jaipur, Rajasthan
Neetu Jain, Meenakshi Sharma, VN Saxena
May-June 2008, 74(3):274-275
DOI:10.4103/0378-6323.41388  PMID:18583809
  6 5,105 387
Dermatomyositis in a human immunodeficiency virus infected person
Yogesh S Marfatia, Ragini A Ghiya, Dipak Chaudhary
May-June 2008, 74(3):241-243
DOI:10.4103/0378-6323.41370  PMID:18583792
It is interesting to study an autoimmune condition like dermatomyositis (DM) in the setting of immunosupression due to human immunodeficiency virus (HIV) infection. An HIV seropositive female aged 30 years, presented with a nonitchy rash over the face, breathlessness, diarrhoea and difficulty in raising her hands above her head. A heliotrope rash around the eyes, Gottron's papules and proximal muscle weakness were found to be present. C reactive protein, erythrocyte sedimentation rate and lactate dehydrogenase levels were raised, but creatinine phosphokinase and anti-nuclear antibody profile were normal. Her HIV serostatus was confirmed by Western blotting, keeping in mind the potential for false positive HIV serology in an autoimmune disorder. Her CD4 count was 379 cells/mm 3 . An X-ray of the chest showed bilateral pleural effusion with raised pleural fluid adenosine deaminase levels. Clinical findings and laboratory investigations favored the diagnosis of DM and HIV infection with tuberculous effusion in an HIV seropositive patient. She was treated with antibiotics, four-drug anti-tubercular treatment, systemic steroids and later, antiretroviral treatment. Chances of a false positive antibody test for HIV should be considered in a patient having an autoimmune disease such as DM.
  5 6,382 319
Successful treatment of multiple gingival pyogenic granulomas with pulsed-dye laser
Sujay Khandpur, Vinod K Sharma
May-June 2008, 74(3):275-277
DOI:10.4103/0378-6323.41389  PMID:18583810
  5 4,994 259
Prevention of mother-to-child transmission
Amar Surjushe, Janak Maniar
May-June 2008, 74(3):200-207
DOI:10.4103/0378-6323.41363  PMID:18583783
  5 8,737 896
An association of Alternaria alternata and Scopulariopsis brevicaulis in cutaneous phaeohyphomycosis
V Anandan, V Nayak, S Sundaram, P Srikanth
May-June 2008, 74(3):244-247
DOI:10.4103/0378-6323.41371  PMID:18583793
Rare molds are increasingly emerging as a cause of deep and invasive fungal infections. We report here a rare case of cutaneous phaeohyphomycosis of the lower limbs due to Alternaria alternata associated with extra-ungual localization of Scopulariopsis brevicaulis. Diagnosis was made based on repeated, direct, microscopic mycological and histological examinations. The study revealed hyphae and fungal cells in a granulomatous dermal infiltrate. Identification of the molds was based on macroscopic appearance on culture of samples from the lesions on Sabouraud's dextrose agar and microscopic appearance on Lactophenol cotton blue following slide culture.
  4 6,638 230
Darier's sign: A model for studying dermographism
Despoina Kiorpelidou, Georgios Gaitanis, Ioannis D Bassukas
May-June 2008, 74(3):271-272
DOI:10.4103/0378-6323.41385  PMID:18583807
  4 4,836 260
Ashy dermatosis-like pigmentation due to ethambutol
Neeraj Srivastava, Lakhan S Solanki, Satish Chand, Rajendra S Garbyal, Sanjay Singh
May-June 2008, 74(3):281-282
DOI:10.4103/0378-6323.41393  PMID:18583814
  4 5,594 226
Co-infection with human immunodeficiency virus and tuberculosis
James W.T Elston, Hiten K.B Thaker
May-June 2008, 74(3):194-199
DOI:10.4103/0378-6323.41362  PMID:18583782
  4 5,580 766
Role of free reactive iron in psoriasis
Arpita Ghosh, Soma Mukhopadhyay, Manoj Kar
May-June 2008, 74(3):277-278
DOI:10.4103/0378-6323.41390  PMID:18583811
  3 7,277 252
Saphenous vein graft dermatitis in patients with coronary artery bypass graft
Reena Rai, CR Srinivas, K Vardharaj
May-June 2008, 74(3):278-279
DOI:10.4103/0378-6323.41391  PMID:18583812
  3 4,105 139
Nevoid acanthosis nigricans
Jayanta Kumar Das, Sujata Sengupta, Asok Gangopadhyay
May-June 2008, 74(3):279-280
DOI:10.4103/0378-6323.41392  PMID:18583813
  3 4,049 204
Tumoral calcinosis
Saurabh Jindal, Amar Surjushe, Prajct Sao, DG Saple
May-June 2008, 74(3):282-283
DOI:10.4103/0378-6323.41394  PMID:18583815
  2 3,962 208
Familial acne inversa with acne conglobata in three generations
PVS Prasad, PK Kaviarasan, Joe Mathew Joseph, S Madhuri, P Viswanathan
May-June 2008, 74(3):283-285
DOI:10.4103/0378-6323.41395  PMID:18583816
  2 5,317 263
Resolution of giant Molluscum contagiosum with antiretroviral therapy
Sumit Sen, Parna Bhaumik
May-June 2008, 74(3):267-268
DOI:10.4103/0378-6323.41382  PMID:18583804
  2 4,414 222
Isolated facial palsy in varicella
G Raghu Rama Rao, A Amareswar, Y Hari Kishan Kumar, Radha Rani
May-June 2008, 74(3):261-262
DOI:10.4103/0378-6323.41377  PMID:18583799
  2 4,143 191
Nodule in the nasolabial fold
Tarun Narang, Sunil Dogra, Sanjeev Handa, Bishan Dass Radotra
May-June 2008, 74(3):299-299
  2 3,145 166
Observational studies: How to go about them?
Maninder Singh Setia
May-June 2008, 74(3):288-291
DOI:10.4103/0378-6323.41397  PMID:18583818
  2 5,891 488
Unusual cause of saxophone penis
Sanjeev Vaishampayan
May-June 2008, 74(3):270-271
DOI:10.4103/0378-6323.41384  PMID:18583806
  1 7,767 268
Allergic contact dermatitis to phenylephrine
Archana Singal, Jolly Rohatgi, Deepika Pandhi
May-June 2008, 74(3):298-298
  1 2,932 164
Comparison of two diluents of 1% methoxsalen in the treatment of vitiligo
Kiran V Godse
May-June 2008, 74(3):298-298
  1 5,952 197
Acne neonatorum in the eastern Saudi Arabia
Omar M Alakloby, Iqbal A Bukhari, Bassam Hassan Awary, Khalid Mohammed Al-Wunais
May-June 2008, 74(3):298-298
Background: Acne neonatorum (AN) is characterized by a facial eruption of inflammatory and noninflammatory acne lesions in a neonate. Hyperactivity of sebaceous glands, stimulated by neonatal androgens, is implicated in its pathogenesis. Aim: To elucidate the clinical profile of AN in eastern Saudi Arabia. Methods: All patients diagnosed with AN in King Fahd Hospital of the University in Khobar, Saudi Arabia, during the year 2005 were evaluated clinically. Results: AN was diagnosed in 26 patients (male/female ratio 1:1). The lesions included mainly facial comedones (30.8%); papules and pustules (15.3% each); and combination of papules, pustules, and cysts (53.4%). Conclusion: All patients recovered spontaneously. In 50% of the cases, one of the parents reported having had acne vulgaris during adolescence. Hereditary factors seem to play a significant role in our series.
  1 3,911 182
Use of anti-retrovirals in pediatric HIV infection
Sunanda Gaur
May-June 2008, 74(3):208-214
DOI:10.4103/0378-6323.41364  PMID:18583784
  1 4,971 545
From the desk of the guest editor
JK Maniar
May-June 2008, 74(3):193-193
DOI:10.4103/0378-6323.41361  PMID:18583781
  1 2,750 229
Color Atlas and Synopsis of Pediatric Dermatology
KK Raja Babu
May-June 2008, 74(3):292-292
  - 3,532 157
Early antiretroviral therapy: The pendulum shifts again
DG Saple, Saurabh Jindal, Satish Vaidya
May-June 2008, 74(3):189-192
DOI:10.4103/0378-6323.41360  PMID:18583780
  - 4,842 368
Necrotizing fasciitis in an HIV-infected patient
Amar Surjushe, Resham Vasani, Minal Thakre, DG Saple
May-June 2008, 74(3):268-270
DOI:10.4103/0378-6323.41383  PMID:18583805
  - 3,271 171
Type 1 lepra reaction presenting as immune reconstitution inflammatory syndrome
Alwyn Rapose
May-June 2008, 74(3):265-266
DOI:10.4103/0378-6323.41380  PMID:18583802
  - 3,563 261
Emerging issues in HIV infection
Harshal T Pandve, JS Bhawalkar, PA Bhuyar
May-June 2008, 74(3):266-267
DOI:10.4103/0378-6323.41381  PMID:18583803
  - 3,891 206
ErbB2: Nonimmune genetic key to leprosy
Bell Raj Eapen
May-June 2008, 74(3):272-273
DOI:10.4103/0378-6323.41386  PMID:18583808
  - 2,874 219
Authors' reply
Viroj Wiwanitkit
May-June 2008, 74(3):273-274
  - 2,250 94
Polymorphic ecthymatoid dermosporidiosis
A Ghorpade
May-June 2008, 74(3):298-298
We report the case of a young Chhattisgarhi male with polymorphic dermosporidiosis (cutaneous rhinosporidiosis). He had multiple subcutaneous nodules and an ecthymatoid skin lesion along with nasal rhinosporidiosis. The diagnosis was confirmed by demonstration of sporangia with endospores in fine-needle aspiration cytology (FNAC), histopathology, and imprint smear from the skin lesions. Treatment was by surgical excision, electrocoagulation, and dapsone. There was no recurrence. Dermatologists should be aware of the diverse cutaneous manifestations of this primarily nasal disease. This is the second published report of polymorphic dermosporidiosis, and the first one reporting an ecthymatoid lesion.
  - 2,872 124
Obituary - Dr. Paruchuri Rajaram
A Kavitha
May-June 2008, 74(3):295-295
  - 2,929 92
Obituary - Dr. Vimal Kumar Agrawal
Sanjay Khare
May-June 2008, 74(3):296-296
  - 3,638 91
Obituary - Dr. A. C. Parikh
RG Valia
May-June 2008, 74(3):297-297
  - 2,404 96
An annular, verrucous, and pruritic plaque on the back
Harun Ciralik, Ozer Arican
May-June 2008, 74(3):293-294
DOI:10.4103/0378-6323.41399  PMID:18583819
  - 2,971 180
Premarital testing for HIV infection: Marriage bureaus should lead
Harshal T Pandve
May-June 2008, 74(3):215-216
DOI:10.4103/0378-6323.41365  PMID:18583785
  - 4,634 226
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